treatment for thoracic outlet syndrome - cochrane review

Treatment for thoracic outlet syndrome (Review)

Povlsen B, Belzberg A, Hansson T, Dorsi M

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2010, Issue 1

http://www.thecochranelibrary.com

Treatment for thoracic outlet syndrome (Review)

Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

http://www.thecochranelibrary.com

T A B L E O F C O N T E N T S

1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . .18INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

iTreatment for thoracic outlet syndrome (Review)


[Intervention Review]

Treatment for thoracic outlet syndrome

Bo Povlsen1, Allan Belzberg2, Thomas Hansson3, Michael Dorsi2

1Department of Orthopaedics, Guy’s and St Thomas’ Hospitals NHS Trust, London, UK. 2Department of Neurosurgery, The JohnsHopkins Hospital, Baltimore, USA. 3Plastic Surgery, Hand Surgery and Burns, University Hospital, Linkoping, Sweden

Contact address: Bo Povlsen, Department of Orthopaedics, Guy’s and St Thomas’ Hospitals NHS Trust, St Thomas Street, London,SE1, UK. [email protected]. [email protected].

Editorial group: Cochrane Neuromuscular Disease Group.Publication status and date: New, published in Issue 1, 2010.Review content assessed as up-to-date: 16 June 2009.

Citation: Povlsen B, Belzberg A, Hansson T, Dorsi M. Treatment for thoracic outlet syndrome. Cochrane Database of Systematic Reviews2010, Issue 1. Art. No.: CD007218. DOI: 10.1002/14651858.CD007218.pub2.


A B S T R A C T

Background

Thoracic outlet syndrome (TOS) is one of the most controversial clinical entities in medicine. Despite many reports of operative andnon-operative interventions, rigorous scientific investigation of this syndrome leading to evidence based management is lacking.

Objectives

To evaluate the beneficial and adverse effects of the available operative and non-operative interventions for the treatment of thoracicoutlet syndrome.

Search strategy

We searched the Cochrane Neuromuscular Disease Group Trials Specialized Register (July 2009), The Cochrane Central Register ofControlled Trials (The Cochrane Library Issue 2, 2009), MEDLINE (January 1966 to June 2009), EMBASE (January 1980 to June2009), CINAHL (January 1981 to June 2009 ), AMED (January 1985 to June 2009 ) and reference lists of articles.

Selection criteria

We selected randomized or quasi-randomized studies in any language of participants with the diagnosis of any type of thoracic outletsyndrome (neurogenic, vascular, and ’disputed’). The primary outcome measure was change in pain rating on a validated visual analogor similar scale at least six months after the intervention. The secondary outcomes were change in muscle strength and adverse effectsof the interventions.

Data collection and analysis

Four authors independently selected the trials to be included and extracted data. The one included study was rated for risk of biasaccording to the methods recommended in the Cochrane Handbook for Systematic Reviews of Interventions.

Main results

This review was complicated by a lack of generally accepted criteria for the diagnosis of TOS and had to rely exclusively on the diagnosisof TOS by the investigators in the reviewed studies. There were no studies comparing natural progression with any active intervention.In one trial with a high risk of bias involving 55 participants transaxillary first rib resection decreased pain more than supraclavicularneuroplasty of the brachial plexus. There were no adverse effects in either group.

1Treatment for thoracic outlet syndrome (Review)


mailto:[email protected]

mailto:[email protected]

Authors’ conclusions

This review was complicated by a lack of generally accepted diagnostic criteria for the diagnosis of TOS. There was very low qualityevidence that transaxillary first rib resection decreased pain more than supraclavicular neuroplasty but no randomized evidence thateither is better than no treatment. There is no randomized evidence to support the use of other currently used treatments. There isa need for an agreed definition for the diagnosis of TOS, especially the disputed form, agreed outcome measures and high qualityrandomized trials that compare the outcome of interventions with no treatment and with each other.

P L A I N L A N G U A G E S U M M A R Y

Treatment for thoracic outlet syndrome

Thoracic outlet syndrome (TOS) is one of the most controversial diagnoses in medicine. It is a spectrum of disorders that includesthree related syndromes: a form where the brachial plexus, a collection of nerves in the neck and armpit, is compressed (the neurogenicform); a vascular form involving compression of the subclavian artery or vein, which are major blood vessels of the upper chest; andnon-specific or disputed TOS. Clinical features may include pain in the shoulder and neck which spreads into the arm; weakness;decreased sensation; swelling; and a restricted blood supply to the affected arm.

TOS may result from a variety of abnormalities such as an extra rib in the neck (cervical rib syndrome), differences in the shape of thevertebrae, abnormal bands of tissue beneath the skin (fascial bands), and abnormalities of how muscles in the side of the neck attach tothe bones. TOS is often associated with a history of trauma. There is a lack of widely accepted standards for making the diagnosis, sothat for the purpose of this review we did not use objective criteria but relied exclusively on the diagnosis of TOS in participants by theinvestigators in the reviewed studies. The diagnosis of TOS is often made after other conditions that can cause one-sided symptoms ofarm pain, weakness or sensory loss, or all three, have been excluded. Most people diagnosed with TOS have the disputed form.

This study demonstrated that there is not currently enough evidence that the established interventions for thoracic outlet syndromeare helpful in relieving pain. Until high quality, randomized clinical trials comparing the various interventions for TOS are performed,the decision whether to treat and the appropriate choice of treatment will have to be based on the preferences of the individual andhealth care provider.

B A C K G R O U N D

Thoracic outlet syndrome (TOS) is one of the most controversialclinical entities in medicine. TOS represents a spectrum of disor-ders encompassing three related syndromes: compression of thebrachial plexus (neurogenic TOS), compression of the subclavianartery or vein (vascular TOS), and a non-specific or disputed typeof TOS. The differential diagnosis of unilateral arm pain, weak-ness, or sensory loss, individually or combined, includes all of thesesyndromes. The majority of people with TOS have the disputedform rather than neurogenic or vascular TOS. The objective di-agnosis of (disputed) TOS is a challenge and generally accepteddiagnostic criteria are lacking. TOS may result from a variety ofanomalies such as a cervical rib (cervical rib syndrome), anomalousfascial bands, and abnormalities of the origin or insertion of theanterior or medial scalene muscles. Clinical features may includepain in the shoulder and neck region which radiates into the arm,paresis or paralysis of brachial plexus innervated muscles, loss of

sensation, reduction of arterial pulses in the affected extremity,ischaemia, and oedema (Huang 2004; Wilbourn 1999). Despitemany reports on conservative and surgical intervention, compli-cations, outcomes and success rates, rigorous scientific investiga-tion of this syndrome and its management is lacking. This reviewaimed to systematically examine the evidence for the effectivenessof established interventions for the treatment of TOS.

Epidemiology of TOS

Despite the fact that the term ’thoracic outlet syndrome’ wascoined in 1956 (Peet 1956) there are no good estimates of its preva-lence (Wilbourn 1990). Cadaver dissection has suggested that only10% of the population have what is considered ’normal’ anatomybilaterally of the thoracic outlet (Junoven 1995). The prevalenceof symptomatic TOS has been estimated to be 10 per 100,000



people (Edwards 1999).

Aetiology of TOS

The aetiology and mechanisms underlying TOS are complex andnot well understood. Vascular compromise is estimated to accountfor only 5% of all cases (Fechter 1993). Ninety-five per cent haveonly neurological symptoms. Neurogenic TOS exists in two vari-ations. ’True neurogenic TOS’ with characteristic clinical findingsin the C8/T1 nerve root distribution is rare, and accounts for onlyabout one to three per cent of all cases of TOS. The other varia-tion has been designated ’disputed neurogenic TOS’ and accountsfor at least 90% of all operations for TOS in the United States(Wilbourn 1990). Factors considered influential in the develop-ment of TOS include trauma and the presence of a cervical rib(Sheth 2001).

Symptoms of TOS

Individuals with TOS frequently report pain, which can lead tosignificant disability. The range of complaints reported in the lit-erature includes pain affecting the neck, shoulder, upper extremityor hand. Weakness is another common symptom (Huang 2004;Wilbourn 1999).

Interventions for TOS

Successful prevention and treatment of pain, muscular weaknessand disability related to TOS are clinically challenging and heavilydependent on which of the three types of TOS the person is suf-fering from. While non-operative and operative approaches havebeen described in the literature, no firm evidence exists for anyapproach, in any of the three types of TOS. Non-operative man-agement typically involves strategies to reduce and redistributepressure and traction through the use of physiotherapy (Lindgren1997) or orthoses (Nakatsuchi 1995). There are also several sur-gical approaches described in the literature. Surgical proceduresfall into three main groups: (1) soft-tissue procedures (scaleneusrelease, neurolysis); (2) cervical rib excision; and (3) excision of thefirst thoracic rib (Sheth 2001). The outcome of treatment is saidto be influenced by a number of factors such as gender, worker’scompensation scheme, the position of the arm during work andfixed joint abnormalities (Green 1991).

O B J E C T I V E S

The objectives were to review systematically the evidence fromrandomized or quasi-randomized controlled trials of the effect ofinterventions for the treatment of each of the three (neurogenic,vascular and ’disputed’) types of thoracic outlet syndrome.

M E T H O D S

Criteria for considering studies for this review

Types of studies

We included randomized controlled trials (RCTs) and quasi-ran-domized controlled trials of non-operative and operative interven-tions for the treatment of TOS. Evidence from high quality ob-servational studies is reported in the Discussion.

Types of participants

We included participants receiving any non-operative or operativeinterventions for TOS of any aetiology and type. There was norestriction for age, sex, socioeconomic status, method of diagnosis,or duration of symptoms.

Types of interventions

Any intervention aimed at treating TOS. These included but werenot limited to the following:

1. appliances, for example orthoses and neck collar;2. physical therapies, for example, joint range of motion

exercises, muscle stretching and strengthening;3. medications, for example, non-steroidal anti-inflammatory

drugs (NSAIDs), corticosteroid injections and muscle relaxants;4. operation, both soft-tissue and bony procedures.

Types of outcome measures

Primary outcomes

The primary outcome was change in pain at least six months afterthe intervention preferably measured as change on a validatedvisual analogue or similar scale.

Secondary outcomes

The secondary outcome measures were:1. change in strength of potentially affected muscle groups at

least six months after the intervention measured with MedicalResearch Council scale which ranges from 0 = complete paralysisto 5 = normal;

2. adverse effects of any treatment regimen.Studies with different follow-up periods were combined with ap-propriate adjustments if the assumption of steady rates of changecould be justified.



Search methods for identification of studies

The Cochrane Neuromuscular Disease Group Trials SpecializedRegister was searched (13 July 2009) using the following searchterms: ’Costoclavicular syndrome’, ’Neurovascular syndrome, tho-racic outlet syndrome’, ’Scaleneus anticus syndrome’, ’Thoracicoutlet nerve compression syndrome’, ’Aperture syndrome’, ’tho-racic outlet Nerve compression syndrome’, ’thoracic outlet, Neu-rogenic thoracic outlet syndrome’, ’Neurologic syndrome, tho-racic outlet’, ’Superior thoracic aperture syndrome’, ’Thoracicoutlet neurologic syndrome’, ’Thoracic outlet neurovascular syn-drome’, ’Thoracic outlet syndrome, neurogenic’, ’Thoracic outletsyndrome, vascular’.The above strategy was adapted to search the following: theCochrane Central Register of Controlled Trials (The CochraneLibrary issue 2, 2009), MEDLINE (January 1966 to June 2009);EMBASE (January 1980 to June 2009); CINAHL (January 1982to June 2009); Allied and Complementary Medicine (AMED)(January 1985 to June 2009 ).

Electronic searches

See Appendix 1,Appendix 2, Appendix 3, Appendix 4, Appendix5

Searching other resources

The databases were searched to include non-English reports, butnone of these studies required translation. The bibliographies ofthe identified trials were reviewed for the identification of addi-tional trials.

Data collection and analysis

Selection of studies

Four review authors independently and in duplicate, in a non-blind fashion, examined the title, keywords and abstract of reportsidentified from electronic searching for evidence of three criteria:

• Is it a randomized or quasi-randomized clinical trial?

• Does it involve an intervention for the treatment of TOS?

If the report fulfilled these criteria or if the authors were not ableto assess this from the title, keywords or abstract then the full ar-ticle was obtained. The authors then assessed the methodologicalquality of the selected articles using a standardized grading system,and independently decided upon inclusion. There were no dis-agreements amongst authors regarding the inclusion or exclusionof any of the papers.

Data extraction and management

Two review authors extracted data from the included trial onto adata extraction form independently. The trial authors were con-tacted for further information when appropriate. Data were en-tered into Review Manager by one author and checked by a secondauthor.

Assessment of risk of bias in included studies

For each study included we completed a data extraction form toasses the risk of bias. This took into account: secure method of ran-domization, concealment of allocation, explicit inclusion/exclu-sion criteria, blinding (including blinding of participants, blind-ing of investigators, blinding of outcome assessors), how studiesdeal with baseline differences of the experimental groups, attritionbias, and completeness of follow-up. The trial was graded usingthe methods described in the Cochrane Handbook for SystematicReviews of Interventions (Higgins 2008). We obtained missing in-formation from the authors whenever possible.

Measures of treatment effect

Since we identified only one randomized trial for inclusion, wehave included in the Discussion some prospective trials reportingconsecutive series of patients that were assessed by someone otherthan the person providing the intervention.

Data synthesis

Since only one trial was included, this was not possible.If more than one trial with a specific treatment or prevention ap-proach had been identified, we would have calculated a pooled es-timate of the treatment effect across the trials using the Cochranestatistical package Review Manager. The initial analysis wouldhave been performed with a fixed-effect analysis. We would alsohave assessed if genuine heterogeneity might occur in advance inthe methods section of the protocol and would also have ensuredthat the reasons for any such factors having the potential to causeheterogeneity were made clear in the background section of theprotocol. To identify heterogeneity we would have examined theforest plots. If the confidence intervals of two studies had not over-lapped or the I2 statistic exceeded 50%, heterogeneity would havebeen suspected.

Subgroup analysis and investigation of heterogeneity

Since only one trial was included, this was not possible.For future updates of this review, if the data are available, we willcompare the effect of interventions in the following subgroups ofparticipants:

1. presence or absence of cervical rib or elongated C7transverse process;



2. acute (symptoms less than six months) or chronic(symptoms for six months or more);

3. male or female.

R E S U L T S

Description of studies

See: Characteristics of included studies; Characteristics of excludedstudies.The following databases were searched and potential studies werefound:

• MEDLINE (from January 1966 to 18th June 2009) = 81;• EMBASE (from January 1980 to 18th June 2009) = 226;• CINAHL (from January 1982 to 18th June 2009) = 4;• Allied and Complementary Medicine (AMED) (from

January 1985 to 18th June 2009) = 5;• Evidence based medicine (EBM) reviews: (from 1991 to

18th June 2009) = 0;

• Cochrane Central Register of Controlled Trials(CENTRAL) on 18th June 2009 = 13;

• NMD (from January 1966 to 18th June 2009) = 12.

The total number of studies were 328 in total but there was overlapbetween the databases of 21 studies, so the net total was 301articles. Based on review of the abstracts, full articles were obtainedand reviewed for 33 studies. Of the 33 studies two RCTs wereidentified, one RCT was excluded due to insufficient duration offollow-up after the intervention but the other RCT was includedin this review.

Risk of bias in included studies

This review was complicated by a lack of generally accepted diag-nostic criteria for the diagnosis of TOS. We had to rely exclusivelyon the diagnosis of TOS in participants by researchers in the re-viewed studies. This in itself creates a high risk of bias in all theidentified studies.The review authors’ judgements about each methodological qual-ity item for the included study are presented in Figure 1.

Figure 1. Methodological quality summary: review authors’ judgements about each methodological qualityitem for each included study.



Effects of interventions

Transaxillary first rib resection (TFRR) versussupraclavicular neuroplasty of the brachial plexus(SNBP)

One trial (Sheth 2005) was identified. It evaluated the effectsof TFRR (n = 25) versus SNBP (n = 24) on patient reportedpain and numbness in 55 participants with the disputed type ofTOS. Participants with anomalous elongated C7 transverse pro-cesses (cervical ribs), intrinsic weakness (characteristic of neuro-genic TOS), and vascular TOS were excluded. Both interventionsresulted in significantly decreased pain and numbness after surgery.The TFRR conferred superior results with respect to pain ratingon 0 to 100 range VAS scale (39 + 7 versus 61 + 7) with an es-timated difference in the treatment effects of -22.0 (95% CLs -41.9 to -2.1; P = 0.03), pain relief (52 + 8% versus 30 + 78%)estimated difference of 22.0 (95% CLs -0.8 to 44.8, P < 0.05),pain rating on an affective scale (3.7 + 0.4 versus 5.1 + 0.5) esti-mated difference of -1.4 (95% Cls -2.7 to -0.1, P < 0.03). Motorstrength was not formally reported and none of the participantsexperienced adverse effects of the interventions.

D I S C U S S I O N

This review was complicated by a lack of generally accepted diag-nostic criteria for the diagnosis of TOS. We had to rely exclusivelyon the diagnosis of TOS in patients by researchers in the reviewedstudies. We aimed to evaluate the effectiveness of various estab-lished interventions for TOS. An extensive search of the literatureidentified only one study that met our inclusion criteria. Moststudies were retrospective; the few prospective studies that wereidentified lacked randomization or adequate follow-up. It was notpossible to include a disability score as a second outcome measurein this version of the review but it will be included in future up-dates.

Sheth 2005 is the only prospective randomized trial for any es-tablished intervention for TOS with a follow-up of at least sixmonths. This study provides limited support for the effectivenessof both TFRR and SNBP for relieving pain in people with thedisputed type of TOS. In this group of patients TFRR providedsignificantly superior results compared to SNBP for all outcomemeasures. A limitation of this study is that it excluded people withan elongated C7 transverse processes (anomalous cervical rib) orsigns and symptoms of neurogenic or vascular TOS. Thus, the di-agnosis of disputed TOS was based solely on the subjective criteriaset forth by the senior author. There is no report of the socioeco-nomic status of the participants or whether they were involved inongoing litigation. In addition, the participants and assessors werenot blinded to the specific intervention and there was no controlgroup.

Other evidence (from excluded studies)

Interventions for TOS may be divided into non-operative and op-erative. Most patients are prescribed several types of non-opera-tive interventions before surgery becomes an option. Non-oper-ative interventions for TOS aim to decrease the compression onthe brachial plexus, restore neural mobility, and correct muscleimbalance in the cervicoscapular region (Lindgren 1997; Novak1995). Our search identified numerous retrospective studies, afew prospective studies, and one randomized clinical trial of non-operative interventions for TOS. Taskaynatan 2004 performeda randomized prospective trial to investigate the effects of cervi-cal traction added to exercise and heat pack therapy in 40 peoplewith TOS of non-defined type. The participants were randomlydivided into two groups. The control group received heat packtherapy and an exercise program; the experimental group receivedheat pack therapy, an exercise program, and cervical traction. Thefinal outcome was assessed three weeks after the intervention. Out-come measures included response to provocative manoeuvres anda Likert Scale rating of improvement in pain and numbness. Bothinterventions produced improvement in some of the provocativemanoeuvres and pain in most patients (75% control group versus90% experimental group, P > 0.05). The difference in numbnessscores between the groups was statistically significant in favour ofadding cervical traction (80% versus 20%, P < 0.001). Althoughthis study was a randomized controlled trial, it was excluded fromour review because it did not meet the criteria for follow-up of atleast six months. The authors did not describe the method usedfor sequence generation or allocation concealment. In addition,neither the participants nor the investigators were blinded to theinterventions. Thus, the risk of selection and assessment bias washigh.Lindgren 1997 published a prospective descriptive study of 119people with possible TOS who were treated with a non-operativeinpatient rehabilitation program and instructions for home exer-cises to restore the normal function of their cervical spine and up-per thoracic aperture. Patient satisfaction with the interventionat the end of the 11.4 (4 to 24) days inpatient period was 88%.The authors reported following the patients for a mean of 24.6months, but do not provide standardized data at the long-term fol-low-up timepoint. Further, 30 of the 119 patients included in thestudy were found to have pathology other than TOS accountingfor their symptoms. There was no assessment of compliance withthe home exercises. Additional risk of bias was introduced by thelack of comparison groups, blinding, standardization of patientdiagnosis, and use of validated outcome measures.Gülbahar 2005 reported a prospective series of 34 patients witha subtype of disputed TOS, known as droopy shoulder syn-drome, who were prescribed postural correction and shoulder gir-dle strengthening exercises. Compliance and symptom outcomewere assessed at a mean (SD) follow-up of 13.7 (5.0) months, andthe patients were divided into two groups with regard to their ad-herence to exercise programs as regular or irregular. Patients that



completed the exercise program had significantly better results inpain on a VAS scale, satisfaction with the treatment, and radio-graphic assessment. Pretreatment equivalence was not establishedbetween the two groups and there was no randomization, there-fore the risk of selection bias was high.Jordan 2000 conducted a prospective single-blind trial of peoplewith TOS of probable neurogenic type who received intrascaleneinjections of either botulinum toxin or lidocaine and steroids. Onemonth after injection, 14 of 22 patients (64%) in the botulinumgroup reported greater than 50% reduction in symptoms com-pared to 4 of 22 patients in the lidocaine and steroid group. Thereare no data available regarding the method used to allocate thepatients to a specific group, nor any information about the char-acteristics of the patients in each group. Thus, there was a highrisk of selection bias.There are numerous retrospective case series supporting the vari-ous established surgical interventions for TOS including scalenec-tomy, scalenotomy, division of fibrous bands, first rib resection,cervical rib resection or a combination of two or more of theseprocedures from either a supraclavicular or transaxillary approach.However, these retrospective studies lack randomization, blinding,and standardized outcome assessment and therefore have a highrisk for selection, allocation, and assessment bias.There are a few prospective series of consecutive patients that un-derwent surgical intervention for TOS. Martens 1980 reportedon a consecutive series of 67 patients with various types of TOSwho had undergone surgical intervention after failing non-oper-ative therapy. The patients were contacted by telephone or let-ter and their long-term outcomes were categorized as excellent,satisfactory or poor. Surgical approaches included supraclavicular,posterior thoracoplasty and transaxillary. Satisfactory results werereported for 75% of posterior thoracoplasty, 64% of supraclavic-ular, and 100% of transaxillary approaches. Statistical analysis tocompare the outcomes between the surgical groups was not re-ported. There was no attempt to randomize patients to the varioussurgical interventions, blind the patients or assessors, or attemptto account for unbalanced attrition rates across the surgical groupsand therefore the risk of selection and assessment bias was high.Sällström 1983 reported on a consecutive series of 63 patients withTOS of whom three had venous thrombosis and the others werenot defined to a specific sub-group, who underwent transaxillaryfirst rib resection. The patients were evaluated at regular intervalsafter surgery with a final evaluation at a mean of 2.5 years. At leastmarked improvement of symptoms was reported by 81% of pa-tients. However, the lack of comparison groups, blinding, and val-idated outcome measures introduce significant risk of assessmentbias. Balci 2003 prospectively studied 47 people with TOS. Theysubdivided the patients into four TOS subtypes: neurogenic upperplexus, neurogenic lower plexus, arterial, and venous. Nineteenpatients had an anomalous cervical rib. Forty-nine surgical proce-dures were performed including first rib resection (n = 28), cervicalrib resection (n =10), first and cervical rib resection (n = 9), and

thrombectomy (n = 2). Follow-up, consisting of clinic visit, phoneconversation, or mailed questionnaire, was conducted at one andtwo months postoperatively and with a long-term follow-up at anaverage of 4.6 years. At long-term follow-up, 75% of upper plexusand 50% of lower plexus patients remained asymptomatic. Therewas no difference in success when the various surgical groups werecompared. The overall morbidity rate was 17% and included inci-sional pain, pneumothorax, intercostobrachial neuralgia, woundinfection, and wound hematoma. The patients were not random-ized to undergo the various surgical interventions, and the out-come measurement was not standardized, therefore the risk of se-lection and assessment bias was high.Landry 2001 reported a prospective observational cohort study ofpeople with disputed TOS who were evaluated by an indepen-dent medical examiner over an eight year period. The authors per-formed the initial examination, but were not involved with anyinterventions. At a mean follow-up of 4.2 years, the study partic-ipants completed a standardized telephone interview or a mailedquestionnaire. Of the 79 survey respondents, 15 had undergonesurgical intervention. Most patients reported improved symptomsand were able to return to work. Surgical intervention did resultin additional relief of symptoms compared to nonoperative ther-apy. The lack of randomization, high attrition rate (42%), and in-adequate patient allocation conferred a high risk of selection andassessment bias.Bhattacharya 2003 reported an observational study of a consec-utive series of 60 patients who had undergone supraclavicularneurolysis or transaxillary first rib resection for TOS of varioustypes. Study participants were identified from a prospective pa-tient database and evaluated using a standardized questionnairethat was mailed or completed over the telephone. The median fol-low-up was 43 months (range 4 to 102 months). At least fair im-provement of symptoms was reported in 90% of the cases. Therewas no difference in outcome with regards to type of TOS or typeof surgical intervention. There was no attempt to randomize pa-tients to various surgical interventions, and the assessors were notblind to which intervention had been performed and therefore therisk of selection and assessment bias was high.

A U T H O R S ’ C O N C L U S I O N S

Implications for practice

This review was complicated by a lack of generally accepted di-agnostic criteria for the diagnosis of TOS. There is currently noevidence demonstrating the beneficial effects of established oper-ative or non-operative interventions compared with natural pro-gression for pain relief in TOS. There is very low quality evidencethat transaxillary first rib resection is superior to supraclavicularneurolysis of the brachial plexus for pain relief in selected people



with the disputed type of TOS that have failed non-operative in-terventions.

Implications for research

There is a need for high quality randomized trials that compare theoutcome of no intervention with the outcome of commonly usedactive interventions. In addition, research is needed to establishobjective diagnostic criteria for the disputed type of TOS and

standardized methods of outcome assessment and reporting.

A C K N O W L E D G E M E N T S

The authors are grateful for the assistance of Professor RichardHughes and Kate Jewitt of the Cochrane Neuromuscular DiseaseGroup.

R E F E R E N C E S

References to studies included in this review

Sheth 2005 {published data only}

Sheth RN, Campbell JN. Surgical treatment of thoracic outletsyndrome: a randomized trial comparing two operations. Journal of

Neurosurgery. Spine 2005;3(5):355–63.

References to studies excluded from this review

Abe 1997 {published data only}Abe M, Shimamura T, Nishida J, Ichinohe K. Diagnosis andtreatment of thoracic outlet syndrome. Journal of Orthopedic Science1997;2:119–27.

Balci 2003 {published data only}Balci AE, Balci TA, Cakir O, Eren S, Eren MN. Surgical treatmentof thoracic outlet syndrome: effect and results of surgery. Annals ofThoracic Surgery 2003;75(4):1091–6.

Bhattacharya 2003 {published data only}Bhattacharya V, Hansrani M, Wyatt MG, Lambert D, Jones NAG.Outcome following surgery for thoracic outlet syndrome. EuropeanJournal of Vascular and Endovascular Surgery 2003;26(2):170–5.

Chang 2009 {published data only}Chang DC, Rotellini-Coltvet LA, Mukherjee D, De Leon R,Freischlag JA. Surgical intervention for thoracic outlet syndromeimproves patient’s quality of life. Journal of Vascular Surgery 2009;49(3):630–7.

Derkash 1981 {published data only}

Derkash RS, Goldberg VM, Mendelson H, McVicker R. Theresults of first rib resection in thoracic outlet syndrome. Orthopedics

1981;4(9):1025–9.

Devin 1984 {published data only}

Devin R, Branchereau A, Laselve L, Hourtoule M. Reflection andevolution of ideas on the thoracic outlet syndrome and resultsregarding the resection of the first rib. Inter Angio 1984;3:189–90.

Divi 2003 {published data only}

Divi V, Proctor MC, Axelrod DA, Greenfield LJ. Thoracic outletdecompression for subclavian vein thrombosis. Experience in 71patients. Archives of Surgery 2003;140(1):54–7.

Gockel 1994 {published data only}

Gockel M, Vastamaki M, Alaranta H. Long-term results ofprimary scalenectomy in the treatment of thoracic outlet syndrome.Journal of Hand Surgery. British volume 1994;19(2):229–33.

Goff 1998 {published data only}Goff CD, Parent FN, Sato DT, Robinson KD, Gregory RT, GayleRG, et al.A comparison of surgery for neurogenic thoracic outletsyndrome between laborers and nonlaborers. American Journal of

Surgery 1998;176(2):215–8.

Gülbahar 2005 {published data only}

Gülbahar S, Akalin E, Baydar M, Sahin E, Manisali M, Kizil R, etal.Regular exercise improves outcome in droopy shouldersyndrome: a subgroup of thoracic outlet syndrome. Journal ofMuscle Pain 2005;13(4):21–6.

Hanif 2007 {published data only}

Hanif S, Tassadaq N, Rathore MF, Rashid P, Ahmed N, Niazi F.Role of therapeutic exercises in neurogenic thoracic outletsyndrome. Journal of Ayub Medical College: JAMC 2007;19(4):85–8.

Johnson 1974 {published data only}Johnson CR. Treatment of thoracic outlet syndrome by removal offirst rib and related entrapments through posterolateral approach: a22 year experience. Journal of Thoracic and Cardiovascular Surgery

1974;68(4):536–45.

Jordan 2000 {published data only}Jordan SE, Ahn SS, Freischlag JA, Gelabert HA, Machleder HI.Selective botulinum chemodenervation of the scalene muscles fortreatment of neurogenic thoracic outlet syndrome. Annals of

Vascular Surgery 2000;14(4):365–9.

Khalil 1975 {published data only}Khalil A, Molokhia F, El-Shawarby A. On the cervical ribsyndrome. Alexandria Medical Journal 1975;21(1):48–58.

Krishnan 2005 {published data only}

Krishnan KG, Pinzer T, Schackert G. The transaxillary approach inthe treatment of thoracic outlet syndrome: a neurosurgicalappraisal. Zentralblatt für Neurochirurgie 2005;66(4):180–9.

Landry 2001 {published data only}Landry GJ, Moneta GL, Taylor LM Jr, Edwards JM, Porter JM.Long-term functional outcome of neurogenic thoracic outletsyndrome in surgically and conservatively treated patients. Journal

of Vascular Surgery 2001;33(2):312–7.

Leffert 1999 {published data only}

Leffert RD, Perlmutter GS. Thoracic outlet syndrome. Results of282 transaxillary first rib resections. Clinical Orthopaedics and

Related Research 1999;368:66–79.



Lindgren 1997 {published data only}

Lindgren KA. Conservative treatment of thoracic outlet syndrome:a 2-year follow-up. Archives of Physical Medicine and Rehabilitation

1997;78(4):373–8.

Martens 1980 {published data only}

Martens V, Bugden C. Thoracic outlet syndrome: a review of 67cases. Canadian Journal of Surgery 1980;23(4):357–8.

Martinez 1982 {published data only}

Martinez NS. Posterior first rib resection for complete thoracicoutlet decompression: evolution, advantages and new technicalaspects. Vascular Surgery 1982;16(6):366–77.

McGough 1979 {published data only}

McGough EC, Pearce MB, Byrne JP. Management of thoracicoutlet syndrome. Journal of Thoracic and Cardiovascular Surgery

1979;77(2):169.

Nakatsuchi 1995 {published data only}

Nakatsuchi Y, Saitoh S, Hosaka M, Matsuda S. Conservativetreatment of thoracic outlet syndrome using an orthosis. Journal of

Hand Surgery. British Volume 1995;20(1):34–9.

Nannapeneni 2003 {published data only}

Nannapaneni R, Marks SM. Neurogenic thoracic outlet syndrome.Neurogenic thoracic outlet syndrome. British Journal of

Neurosurgery 2003;17(2):144–8.

Norgren 1984 {published data only}

Norgren L, Ingesson E, Ribbe E. Results of physiotherapy inthoracic outlet syndrome. Inter Angio 1984;3:139–40.

Qvarfordt 1984 {published data only}

Qvarfordt PG, Ehrenfeld WK, Stoney RJ. Supraclavicular radicalscalenectomy and transaxillary first rib resection for the thoracicoutlet syndrome. A combined approach. American Journal ofSurgery 1984;148(1):111–6.

Roos 1982 {published data only}Roos DB. The place for scalenectomy and first-rib resection inthoracic outlet syndrome. Surgery 1982;92(6):1077–85.

Sanders 1979 {published data only}

Sanders RJ, Monsour JW, Gerber WF, Adams WR, Thompson N.Scalenectomy versus first rib resection for treatment of the thoracicoutlet syndrome. Surgery 1979;85(1):109–21.

Schneider 2004 {published data only}

Schneider DB, Dimuzio PJ, Martin ND, Gordon RL, Wilson MW,Laberge JM, et al.Combination treatment of venous thoracic outletsyndrome: open surgical decompression and intraoperativeangioplasty. Journal of Vascular Surgery 2004;40(4):599–603.

Sällström 1983 {published data only}

Sällström J, Gjöres JE. Surgical treatment of the thoracic outletsyndrome. Acta Chirurgica Scandinavica 1983;149(6):555–60.

Taskaynatan 2004 {published data only}Taskaynatan MA, Balaban B, Yasar E, Ozgul A, Kalyon TA.Cervical traction in conservative management of thoracic outletsyndrome. Journal of Muscular Pain 2004;15(1):89–94.

Terao 2008 {published data only}

Terao T, Ide K, Taniguchi M, Nakauchi J, Isoo A, Takahashi H.The management of patients with thoracic outlet syndrome (TOS)and an assistant diagnosis to discriminate between TOS andcervical spondylosis. Neurological Surgery 2008;36(7):615–23.

Urschel 1976 {published data only}Urschel HC Jr, Razzuk MA, Albers JE, Wood RE, Paulson DL.Reoperation for recurrent thoracic outlet syndrome. Annals ofThoracic Surgery 1976;21(1):19–25.

Additional references

Edwards 1999

Edwards DP, Mulkern E, Raja AN, Barker P. Trans-axillary first ribexcision for thoracic outlet syndrome. Journal of the Royal College of

Surgeons of Edinburgh 1999;44(6):362–5.

Fechter 1993

Fechter JD, Kuscher SH. The thoracic outlet syndrome.Orthopedics 1993;16(11):1243–51.

Green 1991

Green RM, McNamara J, Ouriel K. Long term follow-up afterthoracic outlet decompression. Journal of Vascular Surgery 1991;14

(6):739–46.

Higgins 2008

Higgins JPT, Green S, editors. Cochrane Handbook for SystematicReviews of Interventions 5.0.0 [updated February 2008]. TheCochrane Collaboration 2008. Available from www.cochrane-handbook.org.

Huang 2004

Huang JH, Zager EL. Thoracic outlet syndrome. Neurosurgery2004;55(4):897-2, discussion 902-3.

Junoven 1995

Juvonen T, Satta J, Laitala P, Luukkonen K, Nissinen J. Anomaliesat the thoracic outlet are frequently in the general population.American Journal of Surgery 1995;170(1):33–7.

Novak 1995

Novak CB, Collins ED, Mackinnon SE. Outcome followingconservative management of thoracic outlet syndrome. Journal of

Hand Surgery. American Volume 1995;20(4):542–8.

Peet 1956

Peet RM, Henriksen JD, Anderson TP, Martin GM. Thoracicoutlet syndrome: evaluation of a therapeutic exercise program.Proceedings of the Staff Meetings. Mayo Clinic 1956;31(9):281–7.

Sheth 2001

Sheth RN, Belzberg AJ. Diagnosis and treatment of thoracic outletsyndrome. Neurosurgery Clinics of North America 2001;12(2):295–309.

Wilbourn 1990

Willbourn AJ. The thoracic outlet syndrome is overdiagnosed.Archives of Neurology 1990;47(3):328–30.

Wilbourn 1999Wilbourn AJ. Thoracic outlet syndromes. Neurologic Clinics 1999;17(3):477–97.

! Indicates the major publication for the study



C H A R A C T E R I S T I C S O F S T U D I E S

Characteristics of included studies [ordered by study ID]

Sheth 2005

Methods Randomized clinical trialSequence generation: odd or even hospital record number (not described in text; personalcommunication from authors)Allocation concealment: surgeon aware of hospital record numberBlinding: noIncomplete data: four participants from each group lost to follow-up. Unclear how VASwas performed over the phone or if any of the included questionnaires were incompleteSelective outcome reporting: no description of differences between participants inter-viewed in clinic versus via telephoneOther sources of bias: no description of how ongoing legal claims or dominant extremitywere spread between groups. Both participants with bilateral symptoms were in the samegroupMean duration of follow-up: 37 months

Participants Number: 55 randomized, 47 evaluatedInclusion criteria: Aged 18 years or older with pain as predominant symptom and diag-nosed with TOS by senior author. No improvement with previous physical therapyExclusion criteria: neurologic deficits, symptoms of vascular occlusion, prior TOSsurgery, cervical spondylosis, cervical rib. If patients selected on procedure they wereexcluded.

Interventions Supraclavicular neuroplasty of the brachial plexusTransaxillary first rib resection

Outcomes 1. Paina. score (100 mm VAS)b. relief (Likert scale)c. average, best, worst leveld. location2. Numbness3. Tingling4. Symptom severity with arm raised5. Adverse events

Notes Location: USASocio-economic status: not reported

Risk of bias

Item Authors’ judgement Description

Adequate sequence generation? No Sequence generation: odd or even hospitalrecord number (not described in text; per-sonal communication from authors)



Sheth 2005 (Continued)

Allocation concealment? No Sequence generation: odd or even hospitalrecord number (not described in text; per-sonal communication from authors)

Blinding?All outcomes

No Surgeon knew about hospital number andwas therefore not blinded

Incomplete outcome data addressed?All outcomes

Yes Four participants in each group lost to fol-low-up

Free of selective reporting? Unclear No description of which patients were in-terviewed in person and who by phone

Free of other bias? Unclear Unclear which of the participants had on-going legal claims

Characteristics of excluded studies [ordered by study ID]

Abe 1997 Not a randomized clinical trial. Retrospective series

Balci 2003 Prospective operative series, not randomized

Bhattacharya 2003 Prospective operative series, not randomized

Chang 2009 Prospective operative series, not randomized

Derkash 1981 Not a randomized clinical trial. Retrospective series

Devin 1984 Not a randomized clinical trial. Retrospective series

Divi 2003 Not a randomized clinical trial. Retrospective series

Gockel 1994 Not a randomized clinical trial. Retrospective series

Goff 1998 Not a randomized clinical trial. Retrospective series

Gülbahar 2005 Prospective non-operative series, not randomized

Hanif 2007 Prospective non-operative series, not randomized

Johnson 1974 Not a randomized clinical trial. Retrospective series

Jordan 2000 Prospective non-operative series, not randomized



(Continued)

Khalil 1975 Not a randomized clinical trial. Retrospective series

Krishnan 2005 Not a randomized clinical trial. Retrospective series

Landry 2001 Prospective operative series, not randomized

Leffert 1999 Not a randomized clinical trial. Retrospective series

Lindgren 1997 Prospective non-operative series, not randomized

Martens 1980 Prospective operative series, not randomized

Martinez 1982 Not a randomized clinical trial. Retrospective series

McGough 1979 Not a randomized clinical trial. Retrospective series

Nakatsuchi 1995 Not a randomized clinical trial. Retrospective series

Nannapeneni 2003 Not a randomized clinical trial. Retrospective series

Norgren 1984 Not a randomized clinical trial. Retrospective series

Qvarfordt 1984 Not a randomized clinical trial. Retrospective series

Roos 1982 Not a randomized clinical trial. Retrospective series

Sanders 1979 Not a randomized clinical trial. Retrospective series

Schneider 2004 Prospective operative series, not randomized

Sällström 1983 Prospective operative series, not randomized

Taskaynatan 2004 Randomized clinical trial; Follow-up period < 6 months

Terao 2008 Not a randomized clinical trial. Retrospective series

Urschel 1976 Not a randomized clinical trial. Retrospective series



D A T A A N D A N A L Y S E S

This review has no analyses.

A P P E N D I C E S

Appendix 1. MEDLINE (OvidSP) search strategy

1. randomized controlled trial.pt.2. controlled clinical trial.pt.3. randomized controlled trials/4. random allocation/5. double-blind method/6. single-blind method/7. or/1-68. animals/ not humans/9. 7 not 810. clinical trial.pt.11. exp clinical trials/12. (clin$ adj25 trial$).ti,ab.13. ((singl$ or doubl$ or tripl$ or trebl$) adj25 (blind$ or mask$)).ti,ab.14. placebos/15. placebo$.ti,ab.16. random$.ti,ab.17. research design/18. or/10-1719. 18 not 820. 19 not 921. comparative study/22. exp evaluation studies/23. follow up studies/24. prospective studies/25. (control$ or prospectiv$ or volunteer$).ti,ab.26. or/21-2527. 26 not 828. 27 not (9 or 20)29. 9 or 20 or 2830. Thoracic Outlet Syndrome/ or Thoracic Outlet Syndrome.mp. or TOS.mp.31. nerve compression syndrome.mp.32. Aperture syndrome.mp.33. Superior thoracic aperture syndrome.mp.34. neurologic.mp.35. neurovascular.mp.36. neurogenic.mp.37. vascular.mp.38. or/31-3739. 30 and 3840. Costoclavicular syndrome.mp.41. Scalenus anticus syndrome.mp.42. Superior thoracic aperture syndrome.mp.



43. cervical rib syndrome/ or cervical rib syndrome.mp.44. or/40-4345. 30 or 39 or 4446. exp Therapeutics/47. 29 and 45 and 46

Appendix 2. EMBASE (OvidSP) search strategy

1. Randomized Controlled Trial/2. Clinical Trial/3. Multicenter Study/4. Controlled Study/5. Crossover Procedure/6. Double Blind Procedure/7. Single Blind Procedure/8. exp RANDOMIZATION/9. Major Clinical Study/10. PLACEBO/11. Meta Analysis/12. phase 2 clinical trial/ or phase 3 clinical trial/ or phase 4 clinical trial/13. (clin$ adj25 trial$).tw.14. ((singl$ or doubl$ or tripl$ or trebl$) adj25 (blind$ or mask$)).tw.15. placebo$.tw.16. random$.tw.17. control$.tw.18. (meta?analys$ or systematic review$).tw.19. (cross?over or factorial or sham? or dummy).tw.20. ABAB design$.tw.21. or/1-2022. human/23. nonhuman/24. 22 or 2325. 21 not 2426. 21 and 2227. 25 or 2628. Thoracic Outlet Syndrome/ or Thoracic Outlet Syndrome.mp. or TOS.mp.29. nerve compression syndrome.mp.30. Aperture syndrome.mp.31. Superior thoracic aperture syndrome.mp.32. neurologic.mp.33. neurovascular.mp.34. neurogenic.mp.35. vascular.mp.36. or/29-3537. 28 and 3638. Costoclavicular syndrome.mp.39. Scalenus anticus syndrome.mp.40. Superior thoracic aperture syndrome.mp.41. cervical rib syndrome/ or cervical rib syndrome.mp.42. or/38-4143. 28 or 37 or 4244. exp therapy/45. 27 and 42 and 44



Appendix 3. CINAHL (EBSCOhost) search strategy

S1 (MH “Thoracic Outlet Syndrome”)S2 thoracic outlet syndrome* or TOSS3 (MH “Nerve Compression Syndromes”) or nerve compression syndrome*S4 aperture syndrome*S5 superior thoracic aperture syndrome*S6 neurologic*S7 neurovascular*S8 neurogenic*S9 vascular*S10 S9 or S8 or S7 or S6 or S5 or S4 or S3S11 S2 or S1S12 S11 and S10S13 costoclavicular syndrome*S14 scalenus anticus syndrome*S15 cervical rib syndrome*S16 S15 or S14 or S13S17 S16 or S12 or S11S18 (MH “Therapeutics+”)S19 (MH “Random Assignment”) or (MH “Random Sample”) or (MH “Simple Random Sample”) or (MH “Stratified RandomSample”) or (MH “Systematic Random Sample”)S20 (MH “Crossover Design”)S21 (MH “Clinical Trials+”)S22 (MH “Double-Blind Studies”) or (MH “Triple-Blind Studies”)S23 (MH “Placebos”)S24 (MH “Quasi-Experimental Studies”)S25 (MH “Solomon Four-Group Design”) or (MH “Static Group Comparison”)S26 (MH “Meta Analysis”)S27 (MH “Concurrent Prospective Studies”) or (MH “Prospective Studies”)S28 (MH “Factorial Design”)S29 PT clinical trial or PT systematic reviewS30 ARAB design*S31 ( TI (single* or doubl* or tripl* or trebl*) or AB (single* or doubl* or tripl* or trebl*) ) and ( TI (blind* or mask*) or AB (blind*or mask*) )S32 ( TI (meta?analys* or systematic review*) ) or ( AB (meta?analys* or systematic review*) )S33 ( TI (clin* or intervention* or compar* or experiment* or preventive or therapeutic) or AB (clin* or intervention* or compar* orexperiment* or preventive or therapeutic) ) and ( TI (trial*) or AB (trial*) )S34 (TI (cross?over or placebo* or control* or factorial or sham? or dummy) ) or (AB (cross?over or placebo* or control* or factorialor sham? or dummy) )S35 TI random* or AB random*S36 S35 or S34 or S33 or S32 or S31 or S30 or S29 or S28 or S27 or S26 or S25 or S24 or S23 or S22 or S21 or S20 or S19S37 S36 and S18 and S17



Appendix 4. AMED (OvidSP) search strategy

1. Thoracic Outlet Syndrome/ or Thoracic Outlet Syndrome.mp. or TOS.mp.2. nerve compression syndrome.mp.3. Aperture syndrome.mp.4. Superior thoracic aperture syndrome.mp.5. neurologic.mp.6. neurovascular.mp.7. neurogenic.mp.8. vascular.mp.9. or/2-810. 1 and 911. Costoclavicular syndrome.mp.12. Scalenus anticus syndrome.mp.13. Superior thoracic aperture syndrome.mp.14. cervical rib syndrome.mp.15. or/11-1416. 1 or 10 or 1517. Randomized controlled trials/18. Random allocation/19. Double blind method/20. Single-Blind Method/21. exp Clinical Trials/22. (clin$ adj25 trial$).tw.23. ((singl$ or doubl$ or treb$ or trip$) adj25 (blind$ or mask$ or dummy)).tw.24. placebos/25. placebo$.tw.26. random$.tw.27. research design/28. Prospective Studies/29.. meta analysis/30.. (meta?analys$ or systematic review$).tw.31. control$.tw.32.. (multicenter or multicentre).tw.33. ((study or studies or design$) adj25 (factorial or prospective or intervention or crossover or cross-over or quasi-experiment$)).tw.34. or/17-3335. exp Therapy/36. 16 and 34 and 35

Appendix 5. Cochrane Library CENTRAL search strategy

#1 MeSH descriptor Thoracic Outlet Syndrome explode all trees#2 “Thoracic Outlet Syndrome” or TOS#3 nerve compression syndrome#4 Aperture syndrome#5 “Superior thoracic aperture syndrome”#6 neurologic#7 neurovascular#8 neurogenic#9 vascular#10 (#2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9)#11 (#1 AND #10)#12 Costoclavicular syndrome



#13 Scalenus anticus syndrome#14 Superior thoracic aperture syndrome#15 MeSH descriptor Cervical Rib Syndrome, this term only#16 cervical rib syndrome#17 (#12 OR #13 OR #14 OR #15 OR #16)#18 (#1 OR #11 OR #17)#19 (#18)

H I S T O R Y

Protocol first published: Issue 3, 2008

Review first published: Issue 1, 2010

20 April 2008 Amended Converted to new review format.

C O N T R I B U T I O N S O F A U T H O R S

B Povlsen wrote the first draft of the protocol. M Dorsi wrote the first draft of the review and B Povlsen coordinated the subsequentcomments into the final review. A Belzberg and T Hansson made valuable comments to the subsequent drafts and all participated inassessing the selected papers.

D E C L A R A T I O N S O F I N T E R E S T

None of the members of the review team have conflicts of interest.

S O U R C E S O F S U P P O R T

Internal sources

• Department of Orthopaedics, Guy’s & St Thomas Hospitals NHS Foundation Trust, UK.

External sources

• No sources of support supplied



D I F F E R E N C E S B E T W E E N P R O T O C O L A N D R E V I E W

We did not search evidence based medicine reviews: ACP Journal Club, the Cochrane Database of Systematic Reviews (CDSR) or theDatabase of Abstracts of Reviews of Effects (DARE) in The Cochrane Library.

I N D E X T E R M S

Medical Subject Headings (MeSH)

Brachial Plexus [surgery]; Cervical Rib [surgery]; Randomized Controlled Trials as Topic; Thoracic Outlet Syndrome [diagnosis;etiology; !therapy]

MeSH check words

Humans



treatment for thoracic outlet syndrome - cochrane review

Documents

john wiley

scalenus anticus

thoracic outlet

thoracic outlet

thoracic outlet

ongoing legal

controversial

methodological